Pediatric Managed Medicaid ACO Leverages Pharmacists to Improve Care

September 3, 2019

For a pediatric accountable care organization (ACO) that contracts with Ohio’s Medicaid managed care plans, improving care for children would be a much more difficult job without the expertise of pharmacists who understand the unique needs of those patients.

“Our MCO partners are often really well versed in the adult patient population and chronic diseases that afflict their adult patients — but sometimes the pediatric population’s chronic conditions are different,” Brigid Groves, a clinical pharmacist specializing in population health at Columbus-based Nationwide Children’s Hospital, tells AIS Health.

By Leslie Small

For a pediatric accountable care organization (ACO) that contracts with Ohio’s Medicaid managed care plans, improving care for children would be a much more difficult job without the expertise of pharmacists who understand the unique needs of those patients.

“Our MCO partners are often really well versed in the adult patient population and chronic diseases that afflict their adult patients — but sometimes the pediatric population’s chronic conditions are different,” Brigid Groves, a clinical pharmacist specializing in population health at Columbus-based Nationwide Children’s Hospital, tells AIS Health.

Groves is one of two pharmacists employed by Partners for Kids (PFK), the ACO affiliated with Nationwide Children’s Hospital that receives capitated payments from the state’s five MCOs to manage care for 330,000 children in central and southeastern Ohio.

As an example of how PFK pharmacists intervened to advocate for pediatric patients, Groves points to when the manufacturer of one type of inhaler shifted to a new, non-child-friendly delivery mechanism for the steroid that’s dispensed by the device.

“MCO plans were just kind of like, ‘great new product, put it on there’ [their formularies]. And it really impacted a lot of our kids because they weren’t able to get their steroid inhalers or use them appropriately,” she says. But PFK’s pharmacists explained the situation, and “our plans were then able to make appropriate changes on their formularies.”

One of the MCOs that contracts with PFK, CareSource, is currently making changes to how it covers the immunosuppressive drug Remicade (infliximab), and “we’ve worked with Partners for Kids pharmacists on our clinical criteria for prior authorization with pediatric use of that medication,” adds Nicholas Trego, Pharm.D., associate vice president of pharmacy for the insurer’s Ohio market.

According to the National Health Care Anti-Fraud Association, health insurers lose more than $10 billion each year to health care fraud, waste and abuse. And according to experts, while strides have been made in combatting fraud, there is always going to be some new product ripe for fraud, along with the targets that have been around for years.

Melissa Jampol, an attorney with Epstein Becker Green and former assistant U.S. attorney, tells AIS Health that “insurers need to stay one step ahead of the trends.” She is a big proponent of data analytics, contending that robust analytics help insurers analyze prepayment claims and audit results, trying to prevent fraud before it happens and catch it after the fact.

By Barbra Golub

According to the National Health Care Anti-Fraud Association, health insurers lose more than $10 billion each year to health care fraud, waste and abuse. And according to experts, while strides have been made in combatting fraud, there is always going to be some new product ripe for fraud, along with the targets that have been around for years.

Melissa Jampol, an attorney with Epstein Becker Green and former assistant U.S. attorney, tells AIS Health that “insurers need to stay one step ahead of the trends.” She is a big proponent of data analytics, contending that robust analytics help insurers analyze prepayment claims and audit results, trying to prevent fraud before it happens and catch it after the fact.

Jampol says that opioid use and abuse is still a hot issue. Other targets of health care fraud she sees are telemedicine and durable medical equipment.

Jo-Ellen Abou Nader, vice president of fraud, waste, and abuse and supply chain optimization at Prime Therapeutics LLC, says last year the PBM launched a new data analytics platform to help identify and weed out fraud, waste and abuse.

She adds that “fraud is an evolution.” While health plans are still seeing the same opioid fraud schemes, there are also new schemes trending due to increased access to technology. For example, technology allows fraudulent companies to have more access to patients who don’t have the ability to see a caregiver in person.

Highmark Inc. has also seen a rise in telemedicine schemes involving compounded pain creams. The insurer is combating this type of fraud by identifying large spikes in certain drugs prescribed, says Kurt Spear, vice president of financial investigations and provider review at Highmark. “We can flag those claims, put a stop on them, and do an investigation,” he adds.

Major Insurers Project Medicare Advantage Enrollment Growth in 2019

August 28, 2019

Aetna Inc. and Humana Inc. in recent weeks posted second-quarter 2019 earnings that were aided by substantial growth in their Medicare Advantage segments, while Cigna Corp. expressed confidence in its ability to grow that business in 2020.

CVS Health Corp. on Aug. 7 reported a 55% year-over-year increase in consolidated adjusted operating income to $4 billion, which it mainly attributed to the November 2018 addition of Aetna Inc. and growth of the pharmacy benefit manager.

By Lauren Flynn Kelly

Aetna Inc. and Humana Inc. in recent weeks posted second-quarter 2019 earnings that were aided by substantial growth in their Medicare Advantage segments, while Cigna Corp. expressed confidence in its ability to grow that business in 2020.

CVS Health Corp. on Aug. 7 reported a 55% year-over-year increase in consolidated adjusted operating income to $4 billion, which it mainly attributed to the November 2018 addition of Aetna Inc. and growth of the pharmacy benefit manager.

Aetna this year embarked on its largest MA service area expansion ever, and enrollment in its MA products increased by roughly 33,000 lives from the first quarter of 2019 to 2.26 million members as of June 30. That’s an increase of 30% from 1.73 million MA lives it reported in the year-ago quarter.

Meanwhile, Humana Inc. on July 31 said enrollment in its individual MA plans grew 15.1% from the year-ago quarter to 3.48 million lives as of June 30, 2019, and projected full-year enrollment growth of 16% for the highest individual MA membership increase in a decade.

Humana also updated its projection for an anticipated enrollment decline in its Prescription Drug Plan segment, and said it now expects to lose 700,000 members in 2019 compared to a previous estimate of 700,000 to 750,000 enrollees.

Cigna Corp. on Aug. 1 raised its full-year EPS guidance by 25 cents to 35 cents to a range of $16.60 to $16.90 per share, representing growth of 17% to 19% over 2018. Cigna Corp. President and CEO David Cordani during an Aug. 1 conference call highlighted the “tremendous growth opportunity” in MA for 2020 and said the company expects to achieve between 10% and 15% average annual growth in its MA membership.

Some States Show Interest in Medicaid Funding Caps

August 27, 2019

It’s now been more than seven months since news emerged that the Trump administration wants to use waivers to bring block grants to Medicaid. The administration has since moved closer to doing so, as a document titled “State Medicaid Director Letter: Medicaid Value and Accountability Demonstration Opportunity” has been on the Office of Management and Budget’s website since June 6.

What’s more, some states have made moves that suggest they would try to cap their Medicaid funding if given the green light by CMS. Tennessee is drawing up a waiver request that would move TennCare from an open-ended entitlement program to one with fixed federal payments, in exchange for more flexibility.

By Leslie Small

It’s now been more than seven months since news emerged that the Trump administration wants to use waivers to bring block grants to Medicaid. The administration has since moved closer to doing so, as a document titled “State Medicaid Director Letter: Medicaid Value and Accountability Demonstration Opportunity” has been on the Office of Management and Budget’s website since June 6.

What’s more, some states have made moves that suggest they would try to cap their Medicaid funding if given the green light by CMS. Tennessee is drawing up a waiver request that would move TennCare from an open-ended entitlement program to one with fixed federal payments, in exchange for more flexibility. And Utah recently submitted a waiver proposal that would apply per capita caps to its Medicaid program, giving the state a fixed amount of federal money per enrollee.

“We would expect to see that if they do approve some kind of block grant waiver somewhere, the administration is likely to give that state possibly some pretty favorable financial terms [that] would not be in place for all states,” says Joan Alker, executive director of the Georgetown University Center for Children and Families.

That, she says, would help the administration make the case to Congress to apply Medicaid funding caps to the whole country. “But it would be a sham experiment because congressional proposals are all about significant cuts,” Alker adds.

According to Alex Shekhdar, founder of Sycamore Creek Healthcare Advisors, “there would absolutely be legal challenges” if Medicaid block grant or per capita cap waivers move from concept to reality. Looming over both funding-cap waivers and Medicaid work requirements waivers, he says, “is a conversation about what kind of administrative authority the HHS secretary has.”

Large Employers Are Concerned About Million-Dollar Treatments

August 26, 2019

For large, self-insured U.S. employers, their No. 1 concern related to pharmacy benefits is how to finance treatments that come with seven-figure price tags.

That’s one finding of the National Business Group on Health (NBGH) 2020 Large Employers’ Health Care Strategy and Plan Design Survey. Among the 147 employer respondents, 86% said they were either concerned or very concerned about “the impact of million-dollar treatments getting approved by the FDA.”

By Leslie Small

For large, self-insured U.S. employers, their No. 1 concern related to pharmacy benefits is how to finance treatments that come with seven-figure price tags.

That’s one finding of the National Business Group on Health (NBGH) 2020 Large Employers’ Health Care Strategy and Plan Design Survey. Among the 147 employer respondents, 86% said they were either concerned or very concerned about “the impact of million-dollar treatments getting approved by the FDA.”

“The pipeline is looming — there are an estimated 14 new therapies in excess of $1 million each that are on the docket for FDA approval in the coming months and years,” Ellen Kelsay, NBGH’s chief strategy officer, said at a press briefing in Washington, D.C.

Nearly a quarter of large employers polled said that as of 2019, they are delaying the inclusion of newly launched treatments from their formulary to enable their PBM or health plan to better determine the treatment’s efficacy and safety, the NBGH survey noted.

Kelsay also highlighted the fact that 46% of employer respondents in the 2020 survey indicated they would consider a role for government in helping to negotiate prices for high-cost therapies.

“I think that’s a reflection of the frustration employers have” with how to finance high-cost treatments, NBGH President and CEO Brian Marcotte said at the briefing. “It’s not a question of are these good therapies. It’s a question of what can society afford — not just what can employers afford.”

When it comes to specialty drug management, the most notable area of growth is in the use of prior authorization (PA) for medications billed under the medical benefit. The share of employers using PA for drugs under the medical benefit rose from 36% in 2019 to 59% in 2020.

Aetna, Centene Lose Louisiana Medicaid Contracts for 2020

August 22, 2019

It’s been a rough August in Medicaid managed care in various ways, as is perhaps best illustrated by two publicly traded giants in the field: CVS Health Corp.’s Aetna Medicaid unit and Centene Corp. Both Aetna Better Health of Louisiana and Centene’s Louisiana Healthcare Connections recently learned they lost out on Louisiana’s Medicaid plan contracts for 2020.

The Louisiana Dept. of Health on Aug. 5 announced its intent to contract with four Medicaid managed care organizations — AmeriHealth Caritas Louisiana, Community Care Health Plan of Louisiana (Healthy Blue), Humana Health Benefit Plan of Louisiana, and UnitedHealthcare Community Plan of Louisiana — following a state bid process that began in February.

By Judy Packer-Tursman

It’s been a rough August in Medicaid managed care in various ways, as is perhaps best illustrated by two publicly traded giants in the field: CVS Health Corp.’s Aetna Medicaid unit and Centene Corp. Both Aetna Better Health of Louisiana and Centene’s Louisiana Healthcare Connections recently learned they lost out on Louisiana’s Medicaid plan contracts for 2020.

The Louisiana Dept. of Health on Aug. 5 announced its intent to contract with four Medicaid managed care organizations — AmeriHealth Caritas Louisiana, Community Care Health Plan of Louisiana (Healthy Blue), Humana Health Benefit Plan of Louisiana, and UnitedHealthcare Community Plan of Louisiana — following a state bid process that began in February.

Out of 1,500 maximum points for the MCOs’ RFP, Centene’s subsidiary scored the lowest at 621 points, followed by Aetna’s 669 points, while the four winning plan bidders scored in the 700s or 800s, according to the state health agency’s summary score sheet.

Timing remains an issue as potential legal disputes could further complicate matters. State officials said Louisiana expects to execute the Medicaid contracts on or about Aug. 23. Open enrollment is slated to run from Oct. 15 through Nov. 30, when members can select new plans, but state officials acknowledged the implementation timeline could stall in the event of a protest.

In fact, Aetna and Centene filed protests with the state on Aug. 19 charging that the bidding process was tainted.

“We were shocked and confused by the state’s decision, and very concerned for our 450,000 members,” a Louisiana Healthcare Connections spokesperson told AIS Health on Aug. 15.

“Transitioning a half-million members within 45 days is a massive undertaking, and we are deeply concerned about that transition leading to disruptions in care for our members,” the spokesperson added.